A proposal for a staging system for hyperplastic rhinosinusitis based on the presence or absence of intranasal polyposis.

This study of 30 patients with hyperplastic rhinosinusitis reveals that the major determinant of the success or failure of conservative therapy is the presence or absence of intranasal polyposis. When polyposis is confirmed both clinically and radiographically, surgical intervention appears to be the rational way to handle most cases. When intranasal polyps are not present, an aggressive medical regimen is called for, one that includes a short-term, low-dose oral corticosteroid and an antibiotic, along with periodic radiographic assessment. Regardless of how much disease is seen on computed tomography, if it does not also detect intranasal polyps or masses, the potential for clearing with conservative therapy is extremely high.

Simplified method of staging hyperplastic rhinosinusitis.

There is a need to both classify and simplify the staging of hyperplastic rhinosinusitis. In essence, this is an extension and modification of the staging system proposed by William Friedman in 1990. It is based primarily on computed tomographic scans, but includes a subclassification that relies on the success or failure of conservative therapy, diagnostic endoscopic findings, and, most important, interval radiographic monitoring. Its basic premise is that not all people with nose and sinus complaints need computed tomographic scans. Four stages are outlined with three letter subclassifications for each stage. These subclassifications, divided into A, B, and C, simply denote the success or failure of conservative therapy as monitored by interval radiographic studies. Examples of each stage are given.

Improvement of olfaction following pansinus surgery.

This study involves ten consecutive anosmic patients who underwent pansinus surgery and have been followed and tested a minimum of one year. They all had advanced obstructive bilateral nasal polyposis and pansinusitis. Persistent severe loss of smell was one of the chief complaints in all ten patients. The surgery performed included bilateral nasal polypectomies, bilateral sphenoidethmoidectomies and bilateral nasal antral windows. Post-operatively, all were treated with a topical corticosteroid nasal spray. Seven of these patients were asthmatic and three were also aspirin-sensitive, some being cortisone-dependent. The University of Pennsylvania Smell Identification Test (UPSIT) was administered pre-operatively and then at six-month intervals in the post-operative period. Significant initial improvement in smell acuity occurred in seven of the ten patients. One of the seven, however, developed recurrence of the nasal polyposis and again lost his smell capabilities somewhere between the twelfth and eighteenth post-operative months. Another of the patients who did not improve smell sensitivity post-operatively occasionally is aware of fleeting periods of return.

Intranasal ethmoid sinus surgery, 1980 to 1990.

The Scientific Board of the California Medical Association presents the following inventory of items of progress in otolaryngology/head and neck surgery. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast of these items of progress in otolaryngology/head and neck surgery that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on Otolaryngology/Head and Neck Surgery of the California Medical Association, and the summaries were prepared under its direction.

How I Manage External Otitis in Competitive Swimmers.

In brief: External otitis is the most common ear problem of competitive swimmers and divers. Its main cause is bacteria, but it can also be caused by a fungus (otomycosis) or chronic irritation (neurodermatitis). Although benign and self-limiting, external otitis can jeopardize a swimmer's training program and career if it is ignored. Prevention requires adherence to strict aural hygiene, eg, using alcohol eardrops and not inserting cotton swabs or other instruments into the ear.

Revision sphenoidethmoidectomy.

In 1981, a series of 236 intranasal ethmoidectomy (INE) procedures was reported with a complication rate of 1.8%. Special attention has subsequently been directed to the surgical failures; namely, recurrent nasal polyposis which accounted for approximately 17%. The reason for recurrence in most instances was felt due to failure to do a more thorough posterior ethmoidectomy and enter and clean out the sphenoid sinuses. Subsequently, in all revision cases where a more thorough sphenoidethmoidectomy (RSE) was performed, the overall long-term success rate raised to better than 90%. Attention to skeletonizing the middle turbinate by stripping mucosa and leaving a thin bony shell is an important technical factor. An attempt is made to leave some of this bony skeletonized medial wall of the middle turbinate as it represents the most crucial landmark in doing the surgery via the intranasal route. There still remains approximately 8% to 10% of this patient population with nasal polyposis and sinusitis of such severity that surgery has offered only a temporary measure of relief. In dealing with this group it may be necessary to see these patients postoperatively at four to six-week intervals, carefully suctioning the ethmoid labyrinth and occasionally doing minor office "touch-up" ethmoidectomy-polypectomy procedures to clean off redundant mucosa or early polyposis. This paper is written to offer a compromise to the two schools of intranasal ethmoidectomy surgery as to the necessity of removing the middle turbinate in its entirety.

The intranasal ethmoidectomy: a 12-year perspective.

Two hundred thirty-six intranasal ethmoidectomies were performed on 123 patients during a 12-year period. Four complications representing an incidence of 1.7% are reported with no mortality, blindness, or permanent orbital injuries. An overall 83% (38 patients) success rate in controlling nasal polyposis is recorded in dealing with 46 obstructed nasal polyposis-pansinusitis patients. A subgrouping of 26 patients having had prior polypectomy sinus surgical treatment revealed an 81% (21 patients) control of nasal polyposis. With revision ethmoidectomy surgical treatment, a 91% (42 patients) overall success rate is recorded, and a 92% (24 patients) success rate is noted in the subgrouping. There appears to be no difference between these two groups, implying that the intranasal ethmoidectomy procedure may be the important factor in the control of nasal polyposis.

The overall management of salivary gland disorders.

Two studies are reported in an attempt to give a broader interpretation of the management of salivary gland disorders. One study analyzes 232 patients seen over a six year period and divides the grouping into parotid, submaxillary, and accessory salivary gland disorders. The numbers and percentages of patients who underwent surgery are reported along with a pathological break-down of the various lesions encountered. Eighty-five (36%) of the 232 patients had a documented surgical procedure. Thirty-eight of the entire 232 patients had tumor involvement, for a 16% incidence of neoplasia. At the same time 244 patients had various sorts of salivary gland surgery in the four local hospitals. Of these, 210 had either a parotidectomy or submaxillary gland excision. A surgical and pathological breakdown of the 117 neoplastic lesions fairly well corresponds to most of the published series, but fails to relay the overall picture that the head and neck surgeon encounters in dealing with salivary glands.

Cranial complications of frontal sinusitis.

Complications of frontal sinusitis are potentially serious. The best prevention is adequate antibiotic treatment of acute sinusitis or of the acute exacerbation of chronic sinusitis. Intracranial complications include extradural, subdural and brain abscesses, meningitis and cavernous sinus thrombophlebitis. Bony complications include localized or spreading osteomyelitis. Surgical intervention is often required to prevent unacceptable mortality.

Neurogenic sarcoma of the head and neck.

We discuss our experience in the diagnosis and management of seven cases of neurogenic sarcomas of the head and neck. These uncommon tumors, which affect all ages, arise most frequently from the brachial plexus, sympathetic chain, and the cranial nerves or their branches. An enlarging mass is the most common initially appearing symptom. Diagnosis may be difficult and rests heavily on gross evidence of a relationship between the tumor and its nerve of origin. Histologically, the lesions are composed of spindle cells with varying degrees of pleomorphism in a pattern that is frequently undistinguishable from fibrosarcomas. Ultrastructural studies may be helpful in establishing the neurogenic origin of these tumors. Neurogenic sarcoma of the head and neck has an extremely poor prognosis. Surgery remains the cornerstone of treatment, although radiotherapy is important for palliation.

The medical and surgical approach in management of the unilateral opacified antrum.

The approach to the diagnosis and treatment of the patient with the unilateral opacified maxillary antrum presents a challenging problem. A total of 55 patients have been completely followed over a six-year period. Medical management, immediate, and delayed surgical intervention are discussed over a broad array of cases. Approximately one-half of those cases not requiring immediate surgical intervention recovered on medical management alone. The requirements for eventual surgical intervention and the results are discussed in the remaining cases.

Closure of large nose-cheek groove defects.

Reconstruction of large defects involving the nose-cheek groove area present technical and cosmetic problems. A combination of a cheek falp with a dorsal-nasal rotation flap gives excellent survival and cosmesis for the nose as well as the cheek. The techniques of the dorsal-nasal flap alone and in combination with a cheek advancement flap are demonstrated.